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Biliary-Pancreatic Endoscopic and Surgical Procedures in Patients under Dual Antiplatelet Therapy: A Single-Center Study.

Background/Aims Dual antiplatelet therapy has to be used for at least 1 month after placement of bare metal coronary stents and for a minimum of 1 year after placement of drug eluting stents. Because of the higher risk of bleeding, guidelines strongly recommend to delay elective surgery until dual antiplatelet therapy is ended. However, no data are available regarding the bleeding risk in patients on combined aspirin/clopidogrel therapy undergoing surgical or high-risk endoscopic procedures. Methods We retrospectively analyzed the medical reports of patients on dual antiplatelet therapy, the patients who had to undergo emergency biliary-pancreatic surgery or endoscopic retrograde cholangiography with endoscopic sphincterotomy while in our unit between January 2009 and July 2012. Results In our series, biliary-pancreatic surgical and endoscopic procedures were safely performed in 11 consecutive patients on dual antiplatelet therapy with no evidence of bleeding. Conclusions In emergency, surgical and high risk endoscopic procedures may be performed in patients on dual antiplatelet therapy.

A Rare Cause of Obstructive Jaundice

uestion: An 80-year-old woman was admitted to the ospital because of jaundice, upper abdominal pain, nauea, and vomiting. The patient was on phenprocoumon or chronic atrial fibrillation. Physical examination reealed right upper quadrant tenderness and jaundice. Laboratory studies revealed abnormal coagulation tests ith a prolonged prothrombin time (International Normalzed Ratio 6.0) and a prolonged activated partial thromoplastin time ( 110 seconds). Furthermore, her liver hemistry tests were abnormal with total bilirubin at 12 g/dL, alanine aminotransferase at 170 U/L, aspartate

Gallensteinileus bei Sigmastenose infolge rezidivierender Sigmadivertikulitis – eine seltene Komplikation des Gallensteinleidens

ZusammenfassungHintergrund:Der Gallensteinileus ist eine seltene Komplikation des Gallensteinleidens und eine ungewöhnliche Ursache für die intestinale Obstruktion. Etwa 1–4% aller mechanischen intestinalen Obstruktionen sind durch Impaktion eines oder mehrerer Gallensteine bedingt. Die klinischen Symptome eines Gallensteinileus sind meist unspezifisch.Fallbeschreibung:Eine 82-jährige Patientin wurde mit krampfartigen rechtsseitigen Oberbauchschmerzen und Zeichen eines Dickdarmileus aufgenommen. Anamnestisch war eine rezidivierende Sigmadivertikulitis bekannt. Sonographisch zeigten sich eine Aerobilie und eine ausgeprägte Sigmadivertikulitis mit Ileuszeichen. In der endoskopischen retrograden Cholangiographie stellte sich ein breiter Kontrastmittelaustritt über die Gallenblase in das rechtsseitige Kolon dar. Im Computertomogramm konnten zwei Tonnensteine mit einem Durchmessser von ca. 3 cm, die das Lumen des Sigmas weitgehend verlegten, festgestellt werden. Bei gesichertem Gallensteinileus erfolgte ein chirurgischer Eingriff mit Cholezystektomie, Revision der biliokolischen Fistel und Sigmaresektion.Schlussfolgerung:Dieser Fall zeigt, dass relative Engen des Sigmas nach rezidivierender Divertikulitis eine Prädilektionsstelle für die Impaktion von Fremdkörpern sein können. Der Gallensteinileus stellt nach wie vor eine seltene, aber wichtige Differentialdiagnose bei Patienten mit dem Bild eines mechanischen Ileus dar. Dieses seltene Krankheitsbild kann bei entsprechendem klinischem Verdacht sonographisch und computertomographisch diagnostiziert werden. Die Therapie ist in der Regel chirurgisch, allerdings sind die Komplikationsraten einer chirurgischen Therapie hoch, da die meisten Patienten mit diesem Krankheitsbild höheren Alters sind und häufig eine Vielzahl von Begleiterkrankungen aufweisen. Die definitive Therapie sollte individuell dem Patienten und den entzündlichen Veränderungen der cholezystoenteralen Fistel angepasst werden.AbstractBackground:Gallstone ileus is a rare complication of cholelithiasis and an uncommon cause of intestinal obstruction. It accounts for about 1–4% of all mechanical bowel obstructions. The clinical symptoms and signs of gallstone ileus are mostly nonspecific.Case Report:An 82-year-old woman with recurrent diverticulitis of the sigmoid was admitted because of cramping right upper abdominal pain and signs of large bowel obstruction. Abdominal ultrasound revealed pneumobilia and severe diverticulitis of the sigmoid with signs of ileus. Endoscopic retrograde cholangiography visualized the cholecystoenteric fistula. In addition, computed tomography (CT) scan revealed two stones 3 cm in diameter leading to nearly complete obstruction of the sigmoid. The patient underwent an open cholecystectomy, closure of the cholecystoenteric fistula, and sigmoidectomy.Conclusion:This case report demonstrates that relative stenoses of the sigmoid due to recurrent diverticulitis may predispose to the impaction of foreign bodies. Gallstone ileus is a rare but important differential diagnosis of intestinal obstruction. Ultrasound and CT scans are very helpful in diagnosing gallstone ileus. The treatment is surgical. Unfortunately, surgical therapy of this rare complication is associated with a high morbidity and mortality rate due to multiple comorbidities and age-related problems of these patients. The management of patients with gallstone ileus should be individualized.BACKGROUND Gallstone ileus is a rare complication of cholelithiasis and an uncommon cause of intestinal obstruction. It accounts for about 1-4% of all mechanical bowel obstructions. The clinical symptoms and signs of gallstone ileus are mostly nonspecific. CASE REPORT An 82-year-old woman with recurrent diverticulitis of the sigmoid was admitted because of cramping right upper abdominal pain and signs of large bowel obstruction. Abdominal ultrasound revealed pneumobilia and severe diverticulitis of the sigmoid with signs of ileus. Endoscopic retrograde cholangiography visualized the cholecystoenteric fistula. In addition, computed tomography (CT) scan revealed two stones 3 cm in diameter leading to nearly complete obstruction of the sigmoid. The patient underwent an open cholecystectomy, closure of the cholecystoenteric fistula, and sigmoidectomy. CONCLUSION This case report demonstrates that relative stenoses of the sigmoid due to recurrent diverticulitis may predispose to the impaction of foreign bodies. Gallstone ileus is a rare but important differential diagnosis of intestinal obstruction. Ultrasound and CT scans are very helpful in diagnosing gallstone ileus. The treatment is surgical. Unfortunately, surgical therapy of this rare complication is associated with a high morbidity and mortality rate due to multiple comorbidities and age-related problems of these patients. The management of patients with gallstone ileus should be individualized.

Endoscopic biliary sphincterotomy in patients under antithromboembolic therapy

Background Endoscopic sphincterotomy (EST) carries several risks (e. g., pancreatitis and bleeding). The risk of bleeding is increased in patients with a compromised coagulation system, often due to antithromboembolic therapy. Recent guidelines caution to perform endoscopic procedures that carry a high risk of bleeding in these patients. However, data to support current recommendations are scarce, and EST frequently has to be performed as an emergency procedure. Therefore, it was the aim of our retrospective study to evaluate the rate of procedural bleeding in patients undergoing EST in our endoscopy unit while on antithromboembolic therapy. Methods Between March 2005 and August 2015, 1798 consecutive patients underwent EST at HELIOS Hospital in Pforzheim, Germany. Concomitant therapy with anticoagulants and/or antiplatelet agents was noted, and bleeding following sphincterotomy was recorded. Results We observed 54 bleeding events in 1482 patients (3.6 %) without and 20 events in 316 patients (6.3 %) with antithromboembolic therapy. Bleeding was recorded in 7 out of 123 patients (5.7 %) taking aspirin, in one out of 34 patients (2.9 %) taking clopidogrel, and in 12 out of 209 patients under heparin (5.7 %). Compared to controls, no statistically significant increase in the bleeding rate was seen. However, we observed an association between a lower physical health score and increased bleeding rate. If precut was necessary for biliary tract access, the bleeding rate increased significantly (p < 0.01). Conclusion Bleeding following EST is neither increased in patients taking clopidogrel and/or aspirin or heparin and rarely requires transfusion of packed red blood cells nor does it lead to an increased mortality. However, bleeding following EST seems to occur more frequently in patients with a compromised health status or following precut of the papilla.

A patient with a hyperechoic band-shaped structure in the right hepatic vein

Cement (polymethylmethacrylat) is frequently and increasingly used in vertebral surgery. Complications can occur by spillage of this material; however the vast majority of the patients remain free of symptoms and do not require any specific therapy.Internists, gastroenterologists and radiologists regularly performing abdominal ultrasound and computed tomography should be aware of this complication.A case of spillage of cement in the right hepatic vein is presented.

Leiomyosarcoma of the Sigmoid Colon: a Rare Cause of Intestinal Intussusception

Gastrointestinal stromal tumours (GISTs) represent the most common mesenchymal neoplasms in the gastrointestinal tract. However, prior to the recent developments in immunohistochemical diagnostic tools, most GISTs were misdiagnosed as leiomyosarcoma [1]. Lately, leiomyosarcoma is recognised as an extremely rare tumour of the gastrointestinal tract. Because of different treatment options and prognoses, differentiation of both tumour entities based on histological and immunohistochemical criteria is crucial [2].

Granulocytic Sarcoma of the Colon

Abstract Granulocytic sarcoma (GS) is an uncommon tumor of immature myeloid cells. Primary involvement of the gastrointestinal tract (GI) is rare. Herein a case of GS of the ileocecal valve is presented. This article is part of an expert video encyclopedia.

Poorly Differentiated Neuroendocrine Carcinoma of the Sigmoid Colon—a Rare Differential Diagnosis of Malignant Colon Tumours

Neuroendocrine cells are distributed throughout the body and are found in the gastrointestinal tract, pancreas, lungs, thyroid, adrenal glands and many other organs with the gastrointestinal tract having the largest population of neuroendocrine cells [1]. Gastroenteropancreatic neuroendocrine tumours (NET) are a heterogeneous group of tumours arising from different sites with different aggressiveness and prognosis, presenting with a wide spectrum of clinical features. In contrast to well-differentiated NET, the clinical course of poorly differentiated neuroendocrine carcinoma is similar to small cell lung cancer, resulting in a median survival of 6 months without treatment [2]. Neuroendocrine tumours of the colon and rectum are rare. They are usually undifferentiated and are especially aggressive in their clinical behaviour. Prognosis is usually poor.

V.-cava-inferior-Thrombose bei Patientin mit Non-Hodgkin-Lymphom und stattgefundener Wirbelsäulenoperation@@@Partial thrombosis of the inferior vena cava in a patient with non-Hodgkin lymphoma and history of lumbar spine surgery

Complete or partial thrombosis of the inferior vena cava is usually due to pre-existing malformation of the vessel, malignant tumors, ascending thrombosis, or thrombophilic disorders. We report the case of an 81-year-old woman, in whom a partial thrombosis of the vena cava was observed in the CT scan when re-staging was performed after six cycles of R-CHOP because of high-grade malignant non-Hodgkin lymphoma. Before chemotherapy was started, the patient had undergone an operation of the lumbar spine using cement augmentation. Retrospective analysis showed that cement had penetrated a segmental vein and spilled into the vena cava leading to formation of an adhering blood thrombus. The patient was free of symptoms and anticoagulation was started. Spillage of cement frequently occurs in the process of vertebroplasty and kyphoplasty and may result in serious sequelae. As these procedures are increasingly being used, physicians should be aware of these complications if a patient presents with thrombosis of the caval vein or signs of pulmonary embolism.

Submuköse Raumforderung im distalen Ösophagus

ZusammenfassungSubmuköse Raumforderungen im Ösophagus werden häufig bei der Gastroskopie entdeckt, entweder als Zufallsbefund oder weil sie symptomatisch in Form von Passagestörung manifest werden. In der großen Mehrzahl der Fälle handelt es sich um gutartige Tumoren, meistens Leiomyome; eine Vielzahl anderer, aber seltener Tumoren können ebenfalls vorkommen. Die Endosonographie ist die Methode der Wahl, um diese Raumforderungen im Hinblick auf Dignität und auch Notwendigkeit der Verlaufskontrolle abzuklären. Bei Wachstum, vermehrter Symptomatik und ungewisser Dignität sollte eine endoskopische oder chirurgische Resektion erfolgen. Nur sie erlaubt letztlich eine eindeutige histologische und damit prognostische Zuordnung. Im vorliegenden Fall handelt es sich um ein Lymphangiom, einen gutartigen, im Ösophagus äußerst seltenen Tumor.AbstractSubmucosal lesions of the esophagus are frequently discovered during gastroscopy either incidentally or because of symptoms, such as obstruction of the esophageal passage. In the great majority of cases these tumors are benign and are usually leiomyomas. However, numerous other rare benign tumors can also occur. Endosonography is the diagnostic tool of choice to give information in respect of the dignity and also the need to undertake further control follow-up. If there is growth, increase of symptoms or suspected malignancy, patients should undergo endoscopic or surgical resection. Only then can a clear histologically-based diagnosis be made and a prognostic evaluation given. In the present case the patient had a lymphangioma, an extremely rare but benign tumor of the esophagus.